Public Health and Primary Care: Leading the Way for Integration

In this Letter From the Director, NWCPHP's Tao Sheng Kwan-Gett, MD, MPH, explores the integration of primary care and public health.

In this Letter From the Director, NWCPHP's Tao Sheng Kwan-Gett, MD, MPH, explores the integration of primary care and public health.

September 16, 2014

Integration—it's a big buzzword in primary care and public health circles these days. We in primary care and public health know that integration is needed today more than ever to accomplish the Triple Aim of improving population health, improving the patient experience, and decreasing per capita costs of health care. But what do we do? How can we turn buzz into action?

As a pediatrician who practiced for eight years in Seattle before working several years as a communicable disease epidemiologist for Public Health - Seattle & King County, I've lived and worked in both the primary care world and the public health world. Like many of you (I suspect), I've sometimes imagined what it would be like to work in a utopia of integrated systems: a future where healthcare providers can report notifiable conditions by clicking a button on their EMR screens; where new parents receive lactation and parenting support from a public health nurse in the comfort of their own homes; where the prevalence of obesity in a community is mapped by aggregating height and weight data from health information exchanges; where health care providers, community members, and public health professionals convene to prioritize health problems and collaborate on solutions.

Back to the real world. To foster integration, we need change, and change requires individuals willing to invest the time and energy to move organizations to action. Applying John Kotter's well-known 8-step model of change leadership, here's my take on what primary care and public health can do to lead the way on integration:

1. Establish a sense of urgency.Urgency comes not only from the fact that our country ranks near the bottom of wealthy industrialized nations in health outcomes despite having the highest per capita health care costs in the world. We need to act now on integration efforts because health reform stimulated by the Affordable Care Act presents us with a rare historic opportunity that may not open up again for many years.

2. Create the guiding coalition.Integration requires that systems change. And systems in primary care and public health are built and maintained by administrators. Those on the front lines—nurses, social workers, physicians, epidemiologists, educators, and others—are essential to identify problems and brainstorm solutions. But integrating systems requires the work of directors, administrators, and managers. A guiding coalition must include people with power in the organization to make change happen.

3. Develop a change vision.By this I mean "make a business case." While this may sound antithetical to the service ideals of primary care and the population health ideals of public health, let's face reality: in an environment of shrinking health resources, health care systems and health departments are most likely to pursue integration efforts that are aligned with their mission and won't lose money—i.e., efforts that make business sense.

4. Communicate the vision for buy-in.Both the health care and public health worlds communicate with language full of jargon, technical terms, and numbers. But to get the support of Boards of Directors and Boards of Health, we need to be able to make the case for integration initiatives in plain language that includes stories of how change will improve the lives of the communities we serve.

5. Empower broad-based action.Health equity demands that we invest more to help disadvantaged populations improve their health. Since only 10% of health is attributable to health care, providing high quality care is important but it isn't enough to move the needle on the burden of chronic disease. For the poorest and most vulnerable in our society especially, we must collaborate with other sectors to address the social, behavioral, and environmental factors that account for 60% of health. This means partnerships with education, human services, community development, transportation, and community-based organizations.

6. Generate short-term wins.To build support for primary care-public health integration, we need to show that it works. That means starting with modest projects that demonstrate improvement in health outcomes, however modest, on a short time horizon with clear metrics. We can still be visionary, but the first steps need to be solid ones.

7. Never let up.Some projects will fail to demonstrate measurable improvements in health. That doesn't mean that they didn't work. We have to keep trying new things, using the best evidence to guide innovation.

8. Incorporate changes into the culture.Culture is all about language and values. Here in the Pacific Northwest, tribal communities have been introducing us to the term, "Seven Generations," the concept that the health of an individual is the product of three generations in the past, and will influence the well-being of those three generations into the future. The scientific evidence showing the impact of adverse childhood experiences on mental and physical health in adulthood reflects the same truth: healthy children grow into healthy adults who raise healthy children. Those in primary care know this truth from the families they care for. Those in public health know this truth from epidemiologic maps of health disparities. A culture that embraces this truth as a core value will not merely support primary care-public health integration; it will demand it.

Earlier this year, the vision of a future where primary care and public health work hand in hand to improve community health stimulated a new collaboration between the Northwest Center for Public Health Practice at the University of Washington (which I direct), the Northwest Regional Primary Care Association, and the Community Health Association of Mountain and Plains States. Our three organizations formed a workgroup to answer the question: What skills and knowledge do professionals in primary care and public health need to lead integration efforts that will improve the health of their communities?

As one of our first steps, we've created a two-day pilot workshop on primary care-public health integration to be held at the 2014 CHAMPS/NWRPCA Fall Primary Care Conference in Denver, Colorado on October 19–20, 2014. This "learning laboratory" will feature success stories of primary care-public health integration, as well as future scenarios of public health and primary care integration presented by the Institute for Alternative Futures. A session by the Regional Institute for Health & Environmental Leadership will explore how leaders of all styles are needed for enduring change.

The workshop promises to be practical, provocative, and inspirational. We hope you'll join us!